So to answer your question about how it went to that slight different arc, of course we're here today to talk more about other holistic lifestyle based interventions and that journey complimented very well my clinical role. So I'm a neurologist and also I specialize with vision. So a neuro-ophthalmologist and I work in, I'm very grateful for very high quality institutions and have received really fantastic top-notch training. And I realize that sometimes the way that we can improve patients' lives and improve the outcome of their disease does not just depend on a prescription of medication or surgery. And it could be other things that improves their wellbeing, improves their brain resilience, and there is evidence to support these practices. But I think the implementation of it can be a bit more difficult because it really requires the opportunity to talk with the person in front of us to really deliver something that is appropriate for them.

If somebody wants to talk about something else, such as if they're having a chronic disease such as lots of migraines or pain, one of the key things we may talk about could be sleep, but at the first visit that might not be appropriate time to discuss because they may not wish to talk about it, they may wish to talk about the medications that they're currently on, or there are other things where it just feels like it has to be something more. It has to be some other tablet. Sometimes there is. And part of my training is to know what is at the forefront of the signs. So it all kind of started with the combination of wanting to be there in service of my patients and that also coincided very nicely with my own personal journey. So in my training before we recorded, you talked about how you're very involved with teaching and training, so you will know firsthand about how stressful it is in our training to become specialists or just becoming providers.

There is definitely a big difficulty where practitioners or healthcare practitioners would be at risk of burnout of not taking care of themselves and they're taking care of others. And certainly I found myself in that situation where I was working extremely hard, trying to do my best for my patients and really I didn't really have time to cook. I didn't have time to have a proper night's sleep and I would be dragging, grabbing for the sugary things, grabbing for the ultra processed foods and just trying to just get through. And of course I would be at tip top attention and at my best at work. But then what was left after work was really nothing too much for people. I love family members or even for my own self-care, it would be work and eat something unhealthy and sleep and go back to work. So because that is not a very fulfilling, holistic approach, and I started to make a slight change with realizing that I wanted to create a better sense of balance.

So it started with a combination of looking at the kind of things I was grabbing for that sense of like, oh, I just need to grab that sugary thing, just give myself that boost to going, oh, actually what am I eating daily? And what about things like yoga, meditation, physical activity, and broader aspects of that? So that started to impact a lot on my personal life. And also that was something I was sharing with my family because I thought this is tremendous. There is a lot of benefits to all this and there's all this research about it. So what started with me really going really deep is kind of my character. I like to go really deeply to understand something and I go, wow, this is amazing. And then around that time I thought, if this is so important for myself and my family, why am I not talking to it with my patients?

And of course then I'm aware of the fact that anytime we talk about things with our patients, we have to make sure it's validated and it's certified and various other legislations and also regulations appropriately to make sure that we are delivering things to a certain standard. So that's when I delve into a lifestyle medicine, getting the diploma. So there is an international board of lifestyle medicine, which is part of the American College of Lifestyle Medicine and also the British Society and there are certifications. So that's how it started for me to bring it in. And over the years I've been delivering this kind of care to my patients in my clinic. So I work in a national health service, which is a public funded service, and we have huge volumes of patients. And I found that this approach was very well received and actually creating group clinics.

So I also deliver group clinics that allow peer to peer support and discussions of behavior changes or lifestyle interventions that would be suitable, but really coming from the person in front of me talking about something that they feel right to talk about. And of course that evolved further to people saying, oh, if it's so good, why are we not doing more of it? And that's when I realized I needed to talk more about it, which is why I'm so privileged to be on your podcast here. That's the drive for me to write books. So I write lifestyle, holistic care, self-care books based on the interventions and the lifestyle approaches that benefits our brain health and wellbeing.

So yes, of course we can think about things that we can use such as corticosteroids or prednisone as you would call it in the United States as an emergency, very rapid introduction. And then there is this really important discussion about how do we avoid the side effects or minimize the side effects of medications that we give. So the classic thing usually starts off with, for example, in this scenario, the side effects of prednisone could be weight gain, blood sugar dysregulation, problems with the sleep thinning of the bones, reducing the immune system and so forth. A lot of things that we talk about. But then the situation may be that we need to use that medication for its lifesaving intentions. And oftentimes we then talk about when I start talking about the side effects of prednisone, nobody wants to be on it. So then how do we support them?

So that's where I start talking about, okay, at what stage they talk about physical activity, we talk about the kind of foods they're eating. And what's remarkable is I was seeing a lot of people taking on board that kind of conversation, really, really liking that kind of conversation. And classically, people who take prednisone would gain weight. And I was really surprised when we start off with this conversation preparing them to start on prednisone and they come back on the next visit, they've implemented the lifestyle changes, they have lost weight because of course it's all about metabolic health that we were working on. And also it continued to improve whilst they want prednisone. So that's one of the example. The other examples could be that if somebody has a chronic condition that leads to worry and anxiety, that they're going to get another attack of their condition.

So for example, it could be a inflammatory condition like optic neuritis, nerve inflammation. So somebody could have had that and they're worried about could they end up getting a condition called multiple sclerosis or is it some other autoimmune cause of optic neuritis? And how do we prevent that? Then we have to talk about things such as their vitamin D, how do they get that? Could it be sunshine? Do we have to think about supplementation? Then we have to think about their immune system. How is their sleep? How is their gut health? What are all these other things that could be influencing their sense of wellbeing and how is their physical health? And in this condition of optic neuritis, sadly, some people may get one episode and we can't tell whether they could get future attacks and get diagnosis. Multiple sclerosis, part of the conversation would be about how do they build a really strong foundation of health.

I give the example of going, okay, this is one episode. We do not know whether there's going to be another episode, but what you can do is really build the foundation of your health and really create an environment where your immune system would function as optimally as you can within your control. So then we talk about the impact of sleep on the immune system, physical activity, food, the kind of food stress, management of stress, the autonomic nervous system and so forth. Imagine a situation where there is a storm. The building that is deep with its foundation will stay standing despite the storm, but the beach hut that is just doesn't really have foundation, just gets swept away. That kind of concepts seem to really resonate with the people I talk about with the lifestyle. So these kind of things get really, people do like to think about what else can they do to feel better. So it's one of those where, okay, we can't control things sometimes whether we get sick, but we can optimize our health so that if we get sick we are in a better position to recover or to cope with it.

When people suffer from migraines, the most dramatic form of vomiting, shutting out the light, staying in a bedroom, there is only a proportion of it. There is certainly a big number of people who get other things outside of those immediate acute headache episodes. It could be people suffering from brain fog, change your mood, can't quite think straight, don't feel their unusual self feeling dizzy all the time. And that's not visible, and that's the sad thing that's not visible. And of course we do know that there's such a huge impact that it is the top disabling disease for young women. And of course it prefer three to one ratio of women to men. And of course I see a lot of men also who get troublesome migraine. So firstly, it's a neurological condition. Secondly, we think of it really as a problem with sensory regulation, and I tend to go with this concept of it coming from the brainstem, certainly shown a lot by Professor Gold's research.

And then of course there are other networks that come with that, but really it has that origin likely from the brainstem with the trigeminal vascular system and that could get triggered for whatever reason, but there is a genetic tendency for that and contributed by external factors. So a lot of times when we think about what we can do to help people with migraine, for me foundation of it, the absolute foundation is lifestyle approaches to support. For some people, that's enough to cure their migraine, to treat it, and then they just know what they need to do to keep to a regular rhythm so that they don't tip into getting migraine attacks. For some people, they find that taking their medication for migraines become so much more effective because of the lifestyle approaches. And of course the lifestyle approaches also promote wellbeing. And because it's such a debilitating condition, things that can promote sense of wellbeing and improving the brain health is part of all that of people feeling better. So for me, I usually start off with a discussion about lifestyle if it was appropriate, because of course, like I mentioned at the very beginning, sometimes it's not appropriate and I always think of myself as how can I be of service to the person in front of me? If the person in front of me don't want to talk about lifestyle, I wouldn't talk about it because I'm not telling them what to do. It's not a lecture. It's more of what kind of conversation can we have here to support the outcome.

So the CGR piece class of medications have certainly been really exciting development, but the problem is of course it's not a hundred percent of people recover from that. So that kind of background also, same with all the other migraine preventatives, whether it's topiramate or the other classes of medication or Botox for example, or various other medications, it can be effective, can be very effective for some people. But the kind of people who come to me, usually they would've tried quite a number of medications, they prefer not to take medications because of the side effects. And that's where I start talking about, okay, what can they do foundationally with their lifestyle? So I have a very systematic approach to it. I like to be systematic. You can probably tell from my research approach.

So I share this framework where firstly the key principle in migraine, which is really accepted in the conventional community would be about regularity. Regularity is one of the cornerstones of people who have migraine maintaining that and is also certainly known and accepted about things such as sleep and various things like whether there's fluctuations in caffeine drinking or blood sugar swings and such things, so and so forth. And I was thinking about how does this apply with the kind of concept that some people say, okay, do this lifestyle thing. Some people say do that lifestyle things. And it made me think that a lot of these lifestyle things, they make sense and it's hard to just pin it down to one mechanism. It probably has lots of mechanisms. So for example, sleep is one of the approaches I take. So the approach I take is I shorten that to the acronym called brains, which really is about building brain resilience and balancing the autonomic nervous system.

So starting with the building brain resilience, there are few aspects and one of them is sleep. So for example, if we talk about sleep, we can see about how sleep has a detoxification process. If somebody has a good quality sleep in the deep sleep phase, the glymphatic are working to flush out any toxins and such things. We can see that sleep is really important for inflammation or immunity function of that. We can see that sleep is really important for emotional regulation, how people manage stress. We can see the impact of sleep on how people reach for things as a stop gap, and that leads to fluctuations of blood sugar and about energy systems. So that could be that we can see also how sleep could affect the gut, and then we can think about how the gut and the brain is connected. You are so much more of an expert on gut health, so I, I'm sure you have talked a lot about that with your listeners.

So the other aspects, for example, physical activity, so that is another key thing of the brain resilience in addition to sleep and gut health. So physical activity, let me think about how could physical activity be helpful. We know that low to moderate intensity, so-called zone two in the exercise physiology world can be very helpful for a few things. It could be working through the metabolic pathways, improving metabolic flexibility. It could be helping with clearance of the brain toxins because we certainly know that zone two is really helpful when somebody has other conditions like concussion or something like that to help clear things. We know that physical activity can also be a really helpful mood regulator for stress relief. And that comes in with how stress is a big part of the process of migraine. I'll talk about that a bit more in a moment, but this kind of the examples where we go, alright, and then we have nutrition.

So we talk about nutrition and the nutrients that we are getting. What kind of foods, do we have enough magnesium, what's the diversity in the food? Are we limiting ultra processed foods that's affecting the gut microbiome? And are these foods promoting the creation of the shortchange fatty acids, the anti-inflammatory compounds and lots of other beneficial compounds by improving gut health. So from nutrients to what else is in nutrients, of course you get all the different types of minerals. It's not just magnesium. Magnesium is a big part of it of course, which is one of the things I oftentimes start with thinking how are they with their overall nutrition, nutrition and nutrients? And of course that comes in with metabolic health, but it's just another part of the building brain resilience. We do know from the research in migraine that there is strong support for the importance of blood sugar regulation.

So now the question is, is it the dip in blood sugar or is it the spike in blood sugar? I think we can interpret data in different ways and I suspect that it's a combination of both and all that meaning it's probably a case of fluctuations. For example, spikes in blood sugar could trigger inflammation pathways, for example, oxidative stresses. It can affect the blood brain barrier, it could lead to insulin resistance, which then causes also not just the body insulin resistance as brain insulin resistance, how then it affects the energy pathways of how we can use energy better with the glucose or the ketones or the B vitamins. So there are all these aspects that come from the combination of nutrition, nutrients and metabolic health. So those are the kind of examples in building brain resilience. And there is also the mindset approach of how we help people build in the suitable habits.

And then the other part is the balancing of autonomic nervous system. That is really key. People who have migraines oftentimes observe something called a post-stress effect or the holiday migraine or the weekend migraine. It's the come down after a highly stressful period. So it's a very valid comment where people go, it's not stress causing my migraine when I'm stressed, I don't have migraines. It's when I'm relaxed that I get migraine, hence the holiday migraine, the weekends migraine. Of course for some people it's the ramping up of the stress times like the Monday migraines. So it's very individual and this's the key thing we should remember, I think I always try to remind myself certainly that everyone is an individual. All I'm doing is I'm hearing what they're saying, I'm reflecting on their observations, I'm sharing the knowledge I have and see how it comes together in a way that it makes sense for them or not.

So in that situation, like the stress, if there was a case of the come down migrate, the post stress, the come down effect, then we talk about how to regulate the autonomic nervous system better. Your listeners will know very well about what the autonomic nervous system is. Just to briefly summarize, it's the part of the nervous system that helps with automatic functions like blood pressure, pupil dilatation, sweating, heart rate and so forth. And we have two parts and it's not about one being good or one being bad. We need both. And that's why I say it's the balance. So the one part of it's the sympathetic. Some people think of the get up and go or in its extreme the fight of flight, you just have to really get going, the cortisol response and so on and so forth. And of course you have the parasympathetic, the rest and relax or the resin digest.

There's really needed for us to have good quality sleep to digest our food and we need both. For example, waking up in the morning, we need our sympathetic, our cortisol to kick in to get us up and ready. We have a presentation we need to kick in, we have to pay attention and get some tasks. And so it has its value. It's only when it's out of control. When somebody's in a chronic stress mode, they're constantly worried about something or they're not able to manage that because of the circumstances or additional things or with their health or sometimes to do with other things impacting like sleep. I mentioned about how if it's affected, it could affect stress management. And of course stress affects metabolic health. The cortisol causes blood sugar to be higher than it should affect insulin response. So leading to likelihood of insulin resistance, metabolic dysfunction. So it all intertwines both sides of the brain's framework and the autonomic nervous system. I talk about things like mindfulness or visualizations or breath work, mind body connections, and I think that's really, really important for us to think about that we are part and parcel of all of it and seeing which one comes in at that time and really having the approach of working towards all of them to think, okay, which one do I need to position more? And that is when I see the magic happens.

And those foundational aspects I mentioned really reduces the likelihood of people having migraine. When I first start this approach, usually people will kind of commit to three months of doing this and it is see a big change and that's when they notice that, alright, okay, it's good now I have this late night, I'm still okay. Same thing if people get menstrual migraines. Some women get it around the time of the menstruation and they find that they manage all these foundational aspects when they have their menstruation come, oh, not so much of a problem, you see? So it's about reducing the likelihood. And also there are other things that people can do because sometimes yep, there's a little bit of a heavy hangover thing. Then it's a case of, okay, what kind of rescue strategies can we do? Should we do some breath work now we are just going to stop the attack from the worsening.

Do we need to get further things in place? So for example, if somebody's approaching a big deadline like an exam or a big presentation, then it's a case of in the lead up to it being particularly careful with the brain's foundation approach so that when the big presentation comes, the after effects, it's like, oh, it's okay. It's not a massive thing. Or it's like, oh, after the presentation I know I'm going to be more aware of my blood sugar from the food I eat and aware of how much alcohol I'm drinking so that I minimize the tipping over. Because sometimes when there's more and more things adding to the picture than the pot is more likely to boil over.

The headache phase is very classically one-sided, pounding, throbbing with heightened sensitivity to light, to sounds to smells, vomiting, trying to stay still because movement really worsens it. And then there could be, some people think of a separate face, some don't often abort phase, so that could be a quick nap to just stop it. And then after that, there is postdrome, the hangover effect of migraines. Again, it could be similar to the prodrome or it could be a mirror effect of it. So for example, there could be a change in a mood, a thinking process and the way the brain is thinking sharpness making errors, and just people probably thinking what's wrong with my brain? And of course that's the after effects of migraine, the postdrome. And although we classify in such very clear sections, the kind of people I see I suppose would be the more complicated ones where it doesn't very clearly demarcate it like that.

It probably one melds into the other where they often have this low grade vision, dizziness, visual sensitivity and feeling this heavy hangover effect a bit brain foggy, can't quite think straight, mood is changing. And then they get periods of it worsening with more of a headache feeling and then that then settles back down. So there is this chronic effect. So all this reflects that it is rather complex. And of course it could be other things, not just the vision things. The aura could be a sensory change of the body, which is why for some people they may be thought to be having a stroke because in this very dramatic form, some people may get paralyzed on one side and the right emergency setting is to assume it's a stroke, go to the emergency department. And then of course, usually what happens is that it then resolves. There is all the other migraine things, the scan's normal, there is no stroke, but then it's like, ah, that's a complex migraine, a hemiplegic migraine for example. So there are variations of how this is affected. The ones I find that is really very debilitating would be just a chronic low grade effect where people, they just don't feel themselves, they don't feel so sharp, everything is much slower and people don't understand.

Very nice. It comes through with the book. I have this I'm really excited about. I spoke a lot about metabolic health. I find that it's really important with brain energy. So sweet spot for Brain health talks a little bit more about what we spoke about with the inflammation, the brain barrier, and about actually really practical things. It's not about abstinence, not about avoiding blood sugar, it's more about how do we support that. And the third book, which I missed the trick there because I gave that as a present to somebody else. It's called Break Free from Migraines Naturally. So it's a yellow cover and it's really the lifestyle approaches and these books have been well received. Then the other two books are really more like practical action books, workbooks. So sleep is really important. So I've got this workbook called Sleep Better to Thrive and really takes people through little things where they go just go, okay, understanding what's important, but just enough to go, this is enough knowledge now what do I need to do next?

So it's really an action driven book. I'm also very practical. I'm grateful for the lovely feedback and I like gut health conversations so quick. Ultra processed food really comes with that because I see that a lot in my clinical practice about how ultra processed foods affect our brain and our body. And I was addicted maybe too strong a word, but I was really reaching for ultra processed foods as my go-to foods for young. And I find that actually it was really hard to transition and a lot of all the processes I share would be based on researching to what kind of practical things and from my experience. So those are the books. People can find them on Amazon by searching my name, Dr. Sui Wong, s ui WONG, or they can connect with me on my website and I would love to connect with your listeners. My website is dr sui wong md.com, so it's D-R-S-U-I-W-O-N-G md.com. And there is a page for my books. And also what is exciting is the Thursday Tips newsletter. So every Thursday I write a short newsletter. That's just less than a minute, one minute read approximately. I share three tips and I leave the reader with one question. It's a really lovely way for me to connect to my readers people through other people's podcasts. And yeah, it's really nice to hear the feedback. So I love to connect with your listeners through these methods